When public health becomes a public nuisance

The bizarre advice given to us doctors on how to deal with swine flu confirms that top-down scaremongering is destroying medical practice.

T

6 July 2009

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The combination of speculative scaremongering by Britain’s health authorities and increasingly absurd directives to general practitioner (GP) surgeries in response to the current flu outbreak confirms that public health has become a public nuisance.

On 3 July, the UK health minister Andy Burnham (the fourth since the last General Election) announced that the swine flu pandemic could no longer be contained and that there could be 100,000 cases a day by the end of August. In response to the suggestion from a TV interviewer that this could mean 40 deaths a day, the chief medical officer Liam Donaldson agreed that this was possible, and that it could be higher.

Burnham conceded that his figure was ‘a projection’, not a fact - he meant that it was a speculation based largely on ignorance, similar to previous (unfulfilled) predictions of catastrophic mortality from AIDS, mad cow disease and bird flu. Though leading public health authorities cling to the belief that proclaiming nightmare scenarios is useful in raising public awareness of disease, in reality this provokes anxiety out of all proportion to benefit.

On the same day we received in our GP surgery, by fax and email (and no doubt shortly also by post), the latest of the almost daily pandemic flu briefings from the local primary care trust (PCT). The headline barks: ‘PPE procedures to be used for every patient.’ The bulletin continues in the now familiar tone of an exasperated infant school teacher spelling things out for children who suffer from a combination of learning difficulties and attention deficit hyperactivity disorder (though it never goes so far as to explain that PPE stands for ‘personal protective equipment’):

‘GPs are reminded that on seeing a patient with flu-like symptoms they need to follow all guidance on PPE, including wearing a surgical mask, gloves and apron.’

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This is the sort of advice that could only be given by somebody who has never set foot in a GP surgery, certainly not since the onset of the great swine flu scare. The simple fact is that many patients who have been alarmed by the pandemic propaganda take no notice of the advice to stay at home and come to the surgery (and bring their children) and - quite understandably - expect to be seen. So, after they have sat in the waiting room for hours, coughing and spluttering, we are then expected to scrub and gown up as though we were performing open-heart surgery - and then repeat this procedure for the 20 other patients in the queue? Dream on.

I am torn over what has been the most useful guidance we have received from on high. Is it the diagram showing a cross-section of the nasopharynx illustrating how to take a throat swab? Or is it the picture of the container showing how to package the swab for transport to the laboratory? It was also very helpful to receive ‘real examples’ of ‘what not to do’ detailing just how stupid some local GPs have been in misinterpreting simple guidelines. It is shocking to hear that some GPs have even confused World Health Organisation (WHO) pandemic alert algorithm S5a (for dealing with suspected cases) with algorithm S5b (for sporadic cases). Is it any wonder that the pandemic is out of control? Can revalidation come a moment too soon?

GPs who were instructed - as I was - by the Health Protection Agency (HPA) to visit a suspected case of swine flu solely to do a throat swab may be alarmed by the proposals for home visiting in the grand pandemic flu contingency plan. This anticipates that 28.5 per cent (note the decimal place precision) of a predicted 30million cases in the UK (based on a 50 per cent ‘clinical attack rate’) will require visiting at home. By my humble calculations, assuming a four-week period (and assuming, improbably, no GP absenteeism), this would mean about 10 visits a day for every GP working seven days a week. Whether or not this would be of any benefit to these patients, it would certainly bring primary care services to a halt. But, if the epidemiologists want swabs, why not ask patients to do their own? (They could be sent pictures to help them locate their noses and throats.) We do this already with suspected cases of measles and mumps, so why not for flu? Patients are quite capable of doing their own genital swabs for chlamydia. Indeed this suggests another role for the ‘flu friend’: why not ask them to do your chlamydia swabs as well and get even friendlier?

The unfolding swine flu fiasco raises some hypothetical questions. What if the WHO, the HPA, the Department of Health and the rest had declared an embargo on press conferences and public statements? What if they had encouraged the virologists to concentrate their energies in the laboratories (where their achievements have been impressive) and stay away from the TV studios (where their pronouncements have often been ill-judged and alarmist)?

What if the PCTs had simply let GPs respond in the familiar way to cases of flu apparently occurring in an unfamiliar season? Given the evident mildness of the vast majority of swine flu cases (often milder than seasonal flu), it is difficult to believe that this approach would have resulted in any higher morbidity or mortality. It would certainly have led to less anxiety, to a much lower number of confirmed cases and to a vastly lower consumption of marginally effective anti-viral drugs. It would also have prevented much distress to patients, and much disruption to schools and workplaces (not to mention to surgeries, out-of-hours services, and hospitals).

Ah yes, but it could have been worse, comes the doomsday chorus from WHO, HPA, and all the rest. No doubt, the H1N1 virus could mutate to become the most virulent strain since the 1918 flu pandemic that killed 20million people. It could even be worse than the Black Death of 1348 that reduced the population of Europe by a third. Or maybe not. The public health authorities appear to have become incapable of distinguishing between sensible contingency planning and scaremongering propaganda. But instead of quietly admitting at the outset that very little was known about H1N1 and discreetly getting on with the job of preparing a vaccine and testing drugs, they reached for the megaphone. Better, according to the official mantra of twenty-first century risk aversion, ‘to prepare for the worst and hope for the best’. But even if swine flu had turned out to be a more serious illness, it is difficult to see how scaremongering, swabbing, PPE and Tamiflu would have made much difference.

The ascendancy of public health over primary care revealed in the swine flu scare is an ominous trend. The statements of both national and local public health practitioners confirm attitudes of condescension, even contempt, for the individuals traditionally regarded as being at the centre of primary care - patients and GPs. For public health specialists, our patients are merely people committed to unhealthy lifestyles. Their risk factor epidemiology repackages old prejudices: people get ill because they are idle, promiscuous, gluttonous, drunken, and as the spread of swine flu confirms, dirty. They regard GPs as sadly lacking in the moral fervour required to transform the deviant behaviour of our patients.

The outlook of public health would not be of much consequence were it not for the fact that it has, over the past 20 years, acquired a growing influence over primary health care. This is confirmed by the prominent role of public health specialists, who often have little knowledge or experience of General Practice, in primary care trusts. It is also reflected in the shift in the focus of primary care away from the diagnosis and treatment of the illnesses presented by patients towards the attempt to manage the health-related behaviour of the practice population. The burgeoning activities of check-ups and screening are resulting in what might be called an epidemic (perhaps not yet a pandemic) of overdiagnosis and overtreatment particularly in relation to cancer, heart disease and
diabetes.

The moralising propaganda of public health has a generally demoralising effect on society, encouraging fear and anxiety - and attendant sentiments of stigma and blame. It has a degrading effect on medical practice and is corrosive of good relations between doctors and their patients. As the swine flu scare confirms, it is also disruptive of day-to-day medical practice.

Dr Michael Fitzpatrick is the author of Defeating Autism: A Damaging Delusion, published by Routledge (buy this book from Amazon(UK) and The Tyranny of Health: Doctors and the Regulation of Lifestyle (buy this book from Amazon(UK)).